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S E P T E M B E R 2 0 2 0 • O U T P A T I E N T S U R G E R Y . N E T • 3 1 shoulder, hip and knee replacements and rotator cuff repairs. Patients are often given a patient-controlled analgesia pump in recovery. If they experience pain, they push the button and get an additional opioid dose. This method might relieve their discomfort, but it only treats one of the pain's pathways. Plus, the discomfort is addressed way too late in the game because the patient is already in pain and miserable. So, you're playing catchup, leading patients to con- sume higher doses of opioids, which cause constipa- tion and urine retention. They're also groggy and bedridden, which can lead to post-op complications such as deep vein thrombosis (DVT), hypercoagula- bility or damage to the intimal vein wall. The very premise of multimodal analgesia is that pain is not singularly mediated. Pain is actual- ly multi-factorial and, if addressed as such, the negative effects of excessive postoperative opioids can be eliminated. Post-op pain continues to be problematic, even with the paradigm shift from open to minimally invasive orthopedic procedures, and could prevent patients from being able to move around soon after surgery and rehabilitate faster. To address the pain that occurs even in a mini- mally invasive spine procedure — a lower back discectomy, for example — I use a generous amount of local anesthetic as a numbing medica- tion before I make the incision, which ensures the patient's brain doesn't sense the cut being made. We use tubes to assist the insertion of the camera, which spread muscles as opposed to cutting them and reduce the amount of toxins released around the surgical site. While anesthesia is being administered, the anes- thesia provider also provides IV acetaminophen to reduce overall inflammation. Then we give very low doses of an opioid such as fentanyl to help manage intraoperative pain. After the procedure, I add more local to numb the area around the surgical site for another six to eight hours and place an ice pack on the incision to reduce swelling. We get patients up and walking as soon as possible after surgery to reduce common complications such as edemas, embolisms and DVT. This multifaceted process all but eliminates the need for postoperative opioids. If everything is done right, most patients take only a couple of tablets for two or three days. One of the biggest premises of multimodal anesthesia is that if the patient wakes up in pain, it's too late. It means their inflammation is already high and their brain has already processed the pain. Waking up with pain means the patient will be overly sensitive to it and afraid of it, which will lead to a need for more opioids. Waking up with lit- tle to no pain, on the other hand, is an anxiety reducing scenario. Realistic expectations Sending patients home nearly pain-free requires a multi-disciplinary approach. Our pre-op nurses play a critical role in patients' overall recoveries. The nurses set patients' expectations about the length of the surgery and the fact that they'll experience a small amount of post-op pain. They also explain how patients will be expected to ambulate right away after surgery, and that the amount of opioids SMALL PROBLEM Minimally invasive spine surgeries can still cause significant pain that must be properly managed. Midwest Orthopaedics at Rush